Part 11

Upon the night of May 26-27, 1915, this soldier found himself in the position of a sentry, opposite the enemy. He told his comrade that he had to go away for a time, leaned his gun against a tree, disappeared, and did not return. It was then one o’clock in the morning. At six o’clock, he was found two kilometres away from the lines, in a village. He was in front of a barn where his company had been quartered before taking possession of the advanced posts.

He was brought up before the military authorities; but upon stating that in civil life he had wandered off several times without knowing where he was going, he was submitted to neurological examination. There was available a letter from his family physician relative to his antebellum military service. It appeared that he had committed a number of breaches of discipline, and that he was regarded by the physicians as a _déséquilibré_. He had lived with his mother a very quiet and good life; there was no history of sexual irregularity, and no history of illness except a slight catarrhal jaundice. He had frequently suffered from headaches; there had been slight attacks of vertigo of very brief duration. He had never fallen in these fits. From his story it was elicited that he had had absences; his comrades had noticed that he sometimes stopped stock-still with vague eyes, then shortly regained his wits and continued upon his task. Sometimes he would not work without being able to explain why he went away. He would go off for a period and, upon coming to, discover that he had not eaten his meals. There were never, however, any convulsive crises by day or night. He sometimes felt sick, and although there was no medical treatment, from time to time he took bromides upon his own authority, saying he had been ordered to do so by his father. Although habitually of a gentle demeanor, nevertheless he was subject to excessive anger upon slight occasion.

During the mobilizing and first months of the war, both in quarters and at the front, however, his conduct had been that of a good soldier. Suddenly, about March or April, 1915, the nocturnal enuresis began to be frequent again, occurring twice or three times a week; but the patient hid this misfortune as far as possible from his comrades. The captain thought he looked tired and depressed sometimes. Upon the days following the nights with enuresis, there was intense headache and marked moral and physical depression. There was no proof of nocturnal convulsions, and it is very problematical whether there was tongue-biting.

Another odd feature was that the patient, who had been sober in civil life, had become intoxicated several times after going into the army. Physically, he was of low stature, but otherwise well built. Neurologically, he was entirely negative. There was no sign of venereal disease. There were a few stigmata of degeneration; for instance, there was very little hair upon the face, the ears were unequal in size, and the teeth were somewhat anomalously set. Mentally, he was below par; for instance, he could not add mentally two numbers of two digits.

As to his desertion, the patient says he does not know what he did; that he learned of his act only from his comrades in the morning; that he remembered having left his duty _pour aller satisfaire un besoin_.

A specialist in escapes (epileptic fugues).

=Case 62.= (LOGRE, March, 1917.)

An epileptic fugue with recidivism is described by Logre. He described himself as a specialist in escapes. As a schoolboy, he had practised escapes and run away without purpose, and without remembering fully what he had done. His father would bring him back to school. At first they had punished him and then would pardon him. These escapades in his work as a shoemaker caused him to lose various places, but he had been kept by one employer for a long time nevertheless. From 11 years on, this patient had never ceased living either in foreign parts or in prison.

The fugues on military service began to multiply. The military chiefs did not abide the escapades like the schoolmaster or the employer. Every punishment he received had to do with some fugue. Three times he gave himself up to the military authorities. Three times after a few more days’ service or a week in prison, he left the barracks or escaped. There had never been any appeal throughout this history to an alienist. On the declaration of war, he had returned to Belgium and was put into the army; whereupon in January, he carried out a fugue of a few hours which was rewarded with eight days in prison. There was a five-days fugue in July, whereupon he was taken before the council.

Upon investigation, these fugues seemed to have the classical features of epileptic fugues. They were sudden, unconscious, blindly automatic, almost completely forgotten afterwards and of a stereotyped and recidivistic nature. Most of the fugues had been preceded by a slight excess in drinking. An investigation was made to see if there were any convulsive antecedents; none were found. This mental epilepsy, then, it was thought, must be an isolated symptom, free from every motor symptom. But his mother and one of his brothers had also shown a number of attacks of some sort of epilepsy. In all three cases there was impulsivity, unconsciousness, absurdity, recidivism, and refractoriness to treatment. On these grounds the fugue was regarded as pathological and as epileptic probably. The patient himself thought that these _coups-de-tête_ and this mania for running away without knowing where, made really a very ugly fault, particularly in a soldier.

_Re_ such specialists in escapes as Case 62, Lépine speaks of a type of military delinquent which he calls _Ceux qui sautent le mur_. Some of the fugue subjects, as well as other types of imbalance can apparently be held by no possible kind or degree of discipline. They jump any guardhouse or any other form of imprisonment through what amounts to a wild instinct for liberty. In some cases, this instinct appears in a relatively pure form; that is, without any combined tendency to dipsomania and without any sexual factor. Some of them are, in fact, very good soldiers, especially in shock troops. They, in fact, belong to what one might call the good element among delinquents. In the French Army some of them have been old legionaries and have even been, as in Case 62, previously condemned for desertion. They form a curious minority among the wall jumpers. Wall-jumping makes, so to say, the entire pathological phenomenon, and the recidivism is a part of the disease.

A disciplinary case: Epilepsy and other factors.

=Case 63.= (CONSIGLIO, 1917.)

An Italian private in the artillery (father dead of general paresis) had been a victim of infantile convulsions and of convulsions with loss of consciousness up to 18 (convulsions with shouts and violence in the streets of Rome; had to be put in a straight-jacket at the municipal hospital).

He developed more convulsions during antisyphilitic treatment in the military hospital. He was a very poor soldier, of the rough and violent sort, and after eight months of service had to be assigned to a special disciplinary company, with which he remained for fifteen months. Here also he was punished frequently, and was given a period of four months’ imprisonment for refusal to obey the officers. Then for a period of several years he had no convulsions whatever.

During the war he was given to alcoholism, and one day in June, 1916, he struck an officer and ran away to arm himself. He was at this time observed by psychiatrists and declared sane. He was regarded as an emotional and alcoholic epileptic but not as neurotic or psychopathic. He was again placed in a special disciplinary corps.

_Re_ the convulsions which this Italian developed during antisyphilitic treatment, it would be interesting to know whether intravenous injections were used. In case they were used, one might compare the case of this Italian with Bonhoeffer’s volunteer who developed epileptic convulsions after antityphoid inoculation.

_Re_ the insubordination and violence of this Italian, compare remarks of Lépine noted under Cases 59 and 60. _Re_ the “other factors,” compare remarks of Bonhoeffer noted under Case 57.

An epileptic goes through Mons and two years fighting without symptoms. Then strange conduct with amnesia.

=Case 64.= (HURST, March, 1917.)

A private, 26, epileptic from 11 to 18 (mother also epileptic) entered the army at 20, attempted to commit suicide in 1912 (amnestic for this attempt), and went to France with the expeditionary force in August, 1914. The retreat from Mons and further fighting caused no recurrence of the symptoms. September, 1916, he was in fact put in charge of eight men doing guard duty. At this time he was able to get to bed only every other night. The charge of the telephone worried him, as he had never before been made to assume responsibility. After two months of this, he was found one night arresting civilians without cause and driving them before him with fixed bayonet. He was let off court-martial on the medical evidence, and at hospital remained confused and suspicious. November 16, he was seen by a medical officer in a typical attack of petit mal. Of all this, on reaching England December 19, he had no recollection, and was keen to return to duty.

_Re_ the remarkable delay in the return of epilepsy to this soldier of Mons, Bonhoeffer remarks that one of the epileptics observed by him at the Charité Clinic had passed through nine battles, and another through 18 battles before the first attack of epilepsy. Bonhoeffer regarded the strenuous marching as a liberating factor of epilepsy in five cases, actual fighting in seven cases, shell explosions in two cases, and bullet wounds in three.

_Re_ the apparently psychogenic factor in Hurst’s case (epilepsy coming on after assumption of too great responsibilities), compare remarks of Bonhoeffer under Case 57 concerning psychogenic factors. Sir George Savage has called attention to a form of functional epilepsy following shock or injury, in which recovery occurs after removal from the strain, but in which there is a relapse if the men go back to duty.

Therapeutic (antityphoid inoculation) epilepsy.

=Case 65.= (BONHOEFFER, July, 1915.)

A volunteer without psychopathic signs except a slight stuttering, and without psychopathic history of any sort, went into service at 17. After he had been a short time in the field, a shell fragment injured him in the upper part of the thigh. He lay up in hospital four weeks. He then spent four weeks in the reserve.

He was then given antityphoid inoculation, and a half hour afterward had epileptic convulsions. These appeared four times more during the next fortnight, as a rule followed by a delirious excitement. No fever was reported. After the fourth attack, he was transferred to the Charité Clinic.

At the clinic there were no attacks, and there was nothing epileptic to discern in the make-up of the patient. His nervous system was normal to examination. There was, however, one fact in the family history of note, namely, that an older brother of the patient, 20 years of age, suffered from convulsions.

What is the relation of the antityphoid inoculation to the epilepsy? According to Bonhoeffer, we must not forget the family history even if we regard the inoculation as the liberating factor. Curiously enough, the shell injury did not itself serve apparently to bring out the epilepsy. Bonhoeffer has seen three other instances of epileptic attacks or epileptoid phenomena following antityphoid inoculation. However, in the hundreds of thousands of inoculations, it is not to be wondered at perhaps that there should be a number of instances of epileptic attacks. One was a man with severe epileptic taint; in the others, there was a question of pathological intoxication.

_Re_ antityphoid inoculations, a French observer--Paris--remarks that these inoculations may occasionally start up the symptoms of general paresis. Compare in this connection also Case 63, in which a syphilitic developed convulsions during antisyphilitic treatment. The psychogenic factor of intravenous injection itself, with its possible effect upon glands of internal secretion, can hardly be distinguished from purely serological effects. Paris goes so far as to state that he regards it as imprudent to vaccinate a syphilitic subject. He thinks it might be better for a syphilitic subject to contract typhoid or paratyphoid fever than to run the risk of developing paresis. If the soldier happened to be not only syphilitic but alcoholic, then the danger would be larger. Possibly, however, both Bonhoeffer’s case of antityphoid inoculation epilepsy and the cases alluded to by Paris of antityphoid inoculation, are merely statistical accidents.

Shell-shock; (apparently slight) scalp wound: Jacksonian seizures. Operation, decompressing the edematous upper Rolandic region. Recovery.

=Case 66.= (LERICHE, September, 1915.)

A Moroccan of the Seventh Tirailleurs was thrown to the ground by the explosion very near him of a large calibre shell, lost consciousness, and woke up with a slight contusion of the right side of the head. The date of this injury is unknown. He was evacuated to the interior, but stopped May 25, 1915, at the evacuation hospital because his pulse in the train stood at 51. An hour later in the hospital he had a Jacksonian epileptic attack, followed by a left-sided flaccid, brachial monoplegia, and after a quarter of an hour a second crisis, and then a third,--a sort of epileptic status occupying an hour. The attack seemed to start in the left hand. After the crisis, hand and arm became flaccid and inert.

Lumbar puncture in the crisis gave fluid under small tension in a few absolutely limpid drops. The wound was a superficial skin wound as big as a 25-centime piece, near the middle line, roughly corresponding with the upper Rolandic region. It was hardly a wound--a mild abrasion not passing the epidermis; periosteum and bone intact.

The patient was trephined and a thin layer of clot was found over the dura mater. The clot was removed and a crucial incision was made into the dura mater. The brain seemed a little edematous, hemorrhagic and bruised. It soon began to beat and was tamponed.

May 26, complete brachial monoplegia without seizure.

May 27, seizure at 2 in the afternoon, starting in left arm.

The wound was going well and from this time forward no more seizures. May 28, a cast was made for the hand.

June 4, lumbar puncture yielded a clear liquid under the pressure of 58. That evening an hour after the puncture, the brachial monoplegia disappeared. The arm was still a little weak June 5. June 8 the man was evacuated to the auxiliary hospital at Laversine. June 18, complete recovery.

Fall and blow to head: Hysterical convulsions. Cure by studied neglect.

=Case 67.= (CLARKE, July, 1916.)

Clarke had seen in the war but one case of hysterical convulsions, though this particular patient had severe hystero-epileptic fits occurring in series. The man had never suffered from epilepsy and was 20 years of age. He received a slight wound and fell back into the trench a distance of six feet, striking but not contusing the back of his head.

On admission to the hospital he was found drowsy and dull. Fits occurred a week later, following one another at brief intervals in series that lasted one or two hours. The arms would be raised and extended in clonic spasm; the patient would resist violently if held, and then turn to his right side with rigid extension of legs and back in opisthotonos. The eyeballs underwent irregular movements, and there was a well marked hippus. Though the tongue was protruded in these attacks, it was never bitten. It was doubtful whether there was a complete loss of consciousness. Between attacks, the patient was morose and sullen, and showed a varying incoördination of the movements of the left leg, which was anesthetic to the knee. There was also a glove anesthesia of the right forearm and hand. Fields of vision were contracted.

The fits recurred with intervals of a day or two, for a fortnight. The patient was then strictly isolated in a small room with an observation window. His bed was made up on the floor. He then had very slight attacks, as a rule when the nurse came into the ward; no notice was taken of these attacks and in a fortnight they ceased. The paresis of the leg and the anesthesia also cleared up without treatment. He remained in the general ward three weeks longer, at first dull and listless, but later cheerful and active. Clarke suggests that this patient was below normal intelligence.

Shell injury with unconsciousness; delayed attacks of epilepsy: superposed hysterical hemihypesthesia. Previous history consistent with the hypothesis that a genuine epilepsy had been developed.

=Case 68.= (BONHOEFFER, July, 1915.)

An excellent soldier, of good build, 29 years, a member of the _Landwehr_, passed unscathed through eleven battles in the 1914 campaign, but finally succumbed to fragments of shell which struck his chest and the lower part of his thigh. He fell down, nauseated, and lost consciousness. He is said to have struck about him with his arm and to have voided urine. There was a second attack three weeks later, in which he fell upon his face.

In the Charité Clinic he had three attacks, two of them nocturnal, one in the daytime, followed by a long period of somnolence. He once cried out suddenly in the night as if warding off an attack. He complained of headaches, and was often irritated and out of humor. Somatically, there was a hemihypesthesia on the side of the injury.

The history indicates that this patient up to his sixteenth year had been a victim of occasional enuresis, often cried out in his sleep or even rose from bed. Occasionally he suffered from such violent sudden headaches that he would have to sit down. He was easily irritated, and had once been arrested for assault. As a soldier, however, he had never been guilty of any breach of discipline. Mild headaches would follow drinking. These phenomena in the history pointed in the direction of epilepsy. According to Bonhoeffer, we cannot entirely exclude contusion of the brain from the shell injury. However, there were no cerebral symptoms, and the interval before the occurrence of the attacks rather indicates that we are dealing with a genuine epilepsy. As for the hemihypesthesia, this is a hysterical “_superposition_,” which does not interfere, according to Bonhoeffer, with the genuineness of the epilepsy.

Shell-wound; musculocutaneous neuritis: Brown-Séquard’s epilepsy.

=Case 69.= (MAIRET and PIÉRON, January, 1916.)

An infantryman, 30, a gardener, was wounded in the right forearm by a shell fragment, which fractured the ulna, September 7, 1914, at Revercourt. Despite much fragmentation of the bone and suppuration, the wound healed with two cicatrices, where the fragments had gone in and had come out. The scarring process was over in December.

However, in the middle of January, 1915, this man began to suffer from headaches and insomnia, with vertigo and buzzing in the head, “as if an airplane inside.” Sometimes arms and legs would stiffen, and the man would tremble, have to lie down, and even lose consciousness for a quarter of an hour, waking up tired, wandering, and with feelings in his head. These crises, at first occurring every week, later grew frequent. Finally there was a very complete attack, in which he fell out of bed, got up, made several turns about the room, and went back to bed; and in the morning, was dull and disoriented. Accordingly, he was sent to the central military neuropsychiatric service of the general hospital at Montpellier, November 10.

Besides the two extensive cicatrices, there were motor disorders. Pronation and supination were almost impossible, as well as extension of the hand and fingers and abduction of the thumb. There was a radial paralysis without R. D. Electrical excitability of the extensors was diminished on the right. The hand was weak. The right thumb was atrophic. There was a hypertrichosis as well as redness, heat and perspiration of the right hand. There was a hypesthesia for all forms of stimulation in the hand, especially in the radial region; less in the ulnar region. This hypesthesia rose along the posterior surface of the forearm and covered all the territory of the ulnar nerve; but there was a corresponding hyperesthesia in the musculocutaneous distribution, as well as in the internal cutaneous distribution. Above the scar there was a region of complete anesthesia. The hyperesthesia rose higher along the circumflex nerve and the posterior branches of the cervical nerves and included the great occipital distribution, even involving the superficial cervical plexus, though not the territory of the trigemini. There was some hyperesthesia of areas governed by a few dorsal intercostal nerves. There were also spontaneous pains in these hyperalgesic regions. The _musculocutaneous nerve_ could be felt to be _thick and swollen_, indicating a perineuritis. There were no neuropathic stigmata, but the knee-jerks were exaggerated a little more on the right side.

The convulsions appeared two or three times a day, the pain would get worse along the arm, rise to the head, following the hyperesthetic zone, then invade the interior of the head, whereupon objects would appear to turn and the ears would buzz. The right leg, and especially the right arm, would begin to tremble. The man would have to support himself to avoid falling. He saw shadows moving, colored trees, occasionally persons. When the vertigo got stronger, he lost consciousness. The extremities of the right side stiffened and carried on jerky movements. These sometimes extended to the left side. The seizure lasted from five to fifteen minutes, and sometimes occurred in the middle of the night. Fatigue followed but headache disappeared after an attack.

The diagnosis of Brown-Séquard’s epilepsy was made. If the musculocutaneous trunk was compressed, a crisis was produced with pain radiating to the head, obscuration of vision, numbness in the arm, and tremors. Electrical treatment was resorted to for analgesic effect. There was a certain improvement during May, so that the diurnal dizziness disappeared. May 19 he had a period of 24 hours without any vertigo. In June no further improvement occurred.

An operation was performed June 23, 1915. The two cicatrices were excised, and some fragments of cloth were removed. Three Jacksonian crises followed the operation, and there was another seizure next day. Frequent headaches followed without crises. More seizures appeared in the night during July, and their frequency increased. Pains persisted along the arm and in the back of the head; the musculocutaneous perineuritis was still intense. Prolonged baths for the arm were begun August 4, two baths of two hours each, at 40 deg. each day. Following August 10 there was an improvement, which stopped as soon as the baths were omitted, with diminution of the vertigo and the hyperesthesia. This improvement continued; the baths were made to last three hours. There were no attacks from August 21 to 26 whereupon they then returned for two days. The pains had much diminished in the arm but persisted in the occiput. A few night attacks occurred August 30 and 31, September 5 and 6, as well as September 19 and 20, 25 and 26, and 27.